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BCBSTX is partnering with Shannon Medical Center and the San Angelo Diabetes Coalition, one of our Healthy Kids, Healthy Families® grantees, to help raise awareness around the prevention and management of early-onset chronic kidney disease (CKD).

What is the San Angelo Diabetes Coalition?

The San Angelo Diabetes Coalition is a collaborative that began in January 2017 that includes several local entities: Angelo State University, La Esperanza Clinics, San Angelo Community Medical Center, the San Angelo Health Foundation and Shannon Medical Center.

Bringing together these three healthcare entities, along with the university and the local health foundation, allows the coalition to address individual needs and positively impact the overall health of the community.

The coalition’s mission is to improve community health by creating and supporting programs to decrease the incidence and complications of diabetes and address factors that cause the disease.

How does it work?

This grant initiative gave the San Angelo Diabetes Coalition the ability to create a program that focuses on the prevention and management of diabetes and chronic kidney disease (CKD) that supports the overall mission of the coalition.

The staff consists of a Program Coordinator, a Registered Nurse and a Community Health Worker. They partner with healthcare professionals, such as Certified Diabetes Educators, Dietitians and Physical Therapists throughout San Angelo for monthly outreach events, educational seminars, diabetes education classes and more.

This approach allows for multi-faceted community based outreach to reach individuals and families where they are. Individuals are also eligible for one-to-one services with a Community Health Worker to connect with resources to meet their health and social needs.

What does a Community Health Worker do?

The healthcare system can be very complex. A Community Health Worker is a front-line, public health advocate that serves as a bridge between individuals and healthcare systems to help navigate and coordinate services. For example, Community Health Workers help patients get established with a primary care physician and enroll in eligible benefits. They also link patients to available resources and empower them to understand how to manage their disease.

They provide culturally competent outreach, health education and guidance on health behaviors. They also advocate for individual and community needs. Community Health Workers are integrated into healthcare teams, which allows them to improve health equity and community outreach programming.

Meet Mary

Mary Montez became a certified Community Health Worker in September 2016 and joined the staff for the San Angelo Diabetes Coalition in April 2018. Through her certification, on-the-job training and passion for people, she helps each person navigate their chronic condition and become an advocate for their health.

She reaches individuals and families where they live, eat, play, work and pray. Her role consists of one-on-one counseling, outreach education and facilitating partnerships with community service providers to identify appropriate resources within the community. Mary works with individuals on referrals to social service agencies and helps them set achievable health goals.

By building authentic relationships, each individual gains confidence, feels cared about and knows someone is listening to their needs. Mary’s role significantly impacts the success of the program.

Mary’s favorite part of her day-to-day activities is working with people. She serves as the bridge to help individuals better understand how important it is to manage their disease. Mary is constantly finding ways to impact the health of individuals and the San Angelo community.

To learn more about the San Angelo Diabetes Coalition and the HKHF program initiative, please call (325) 657-8249 or follow their Facebook page.

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